HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 100 JOHNNY CAKE STREET 11/21/2023 Commonwealth of Massachusetts
= City/Town of
a System Pumping Record
Form 4
LAM
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351. - -
- _ HOUSE: front back Si rea left
A. Facility Information BUILDING: front back side rear left rig t
Important:When
DECK: under
filling out forms 1. System Location:
on the computer, I�
use only the tab N
key to move your Add�res l
cursor-do not N , CQI�� MA
use the return I yS
key. City/Town State Zip Code
reb 2. System Owner:
R�
Name
rerun
Address(if different from location)
MA
City/Town State ip Code
R*)� -gs-y•lc(d�(
Telephone Number
B. Pumping Record
1. Date of Pumping ft"3 2. Quantity Pumped: ,
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tank Tight
g ❑ Grease Trap
❑ Other (describe): - — - ---
4 Effluent Tee Filter present? ❑ Yes [� No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Ma�iceNmber
1AA95E
Name Vehi
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
LSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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